Professional Documents
Culture Documents
MD CCFP FCFP
Len Kelly
Quality of evidence
A literature review was undertaken; we searched MEDLINE,
EMBASE, and the Cochrane Database of Systematic Reviews
from 1996 to 2007 using MeSH terms rheumatic fever and
rheumatic heart disease for articles focusing on prevention,
epidemiology, or disease management. The abstracts of 600
papers were read, and 60 key articles (either comprehensive
reviews or from established journals) were read in full. Most
were reviews, outbreak descriptions, treatment descriptions,
or secondary prevention program descriptions (levels II and III
evidence). There were no recent randomized controlled trials
owing to the known virulence of the illness, and the only level
I articles were a meta-analysis and a systematic review. Case
series data from medical records at the Sioux Lookout Meno Ya
Win Health Centre in Ontario were also used. Ethics approval
for the case series was obtained from the Sioux Lookout Meno
Ya Win Health Centre Research Review Committee.
Main message
Literature review. Two distinct schools of literature exist
for ARF: studies and commentaries from North America and
Europe that view rheumatic fever as a rare disease and discuss the limited efficacy of screening for streptococcal sore
throat, ARFs presumed precursor; and literature from the
developing world and international aboriginal literature that
documents a robust discussion of the presentations, epidemiology, and control of rheumatic fever and its sequela, rheumatic heart disease (RHD), which is of ongoing relevance.
In a meta-analysis of antibiotics for the primary prevention of ARF in patients with documented pharyngitis (N = 7665),
Robertson et al found a protective effect (relative risk 0.32, 95%
confidence interval 0.21 to 0.48) for a reduction in risk of almost
70% (level I evidence).1 Interestingly, inclusion of randomized
controlled studies done in the 1950s by the US Army might
make such overviews less informative, as they were done in an
era of endemic group A streptococcus (GAS) and ARF.1
Abstract
OBJECTIVE To remind physicians who work with
aboriginal populations of the ongoing prevalence
of acute rheumatic fever and to review the recent
evidence on presentation, treatment, and secondary
prophylaxis.
SOURCES OF INFORMATION The Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE
were searched from 1996 to 2007 with a focus on
prevention, epidemiology, and disease management.
Case series data from medical records at the Sioux
Lookout Meno Ya Win Health Centre in Ontario were
also used.
MAIN MESSAGE Acute rheumatic fever is still a
clinical entity in aboriginal communities in northwest
Ontario. Identification, treatment, and secondary
prophylaxis are necessary.
CONCLUSION Acute rheumatic fever is not a
forgotten disease and still exists in remote areas of
Canada.
Rsum
OBJECTIF Rappeler au mdecin qui travaille avec les
populations aborignes que le rhumatisme articulaire aigu est toujours prsent, et revoir les donnes
rcentes sur son tableau clinique, son traitement et la
prophylaxie secondaire.
SOURCES DE LINFORMATION On a consult la
Cochrane Database of Systematic Reviews, MEDLINE
et EMBASE entre 1996 et 2007, en ciblant surtout la
prvention, lpidmiologie et le traitement de cette
maladie. On a aussi utilis les donnes dune srie de
cas du centre de sant Sioux Lookout Meno Ya Win
en Ontario.
PRINCIPAL MESSAGE Le rhumatisme articulaire
aigu est toujours prsent dans les communauts
aborignes du nord-ouest de lOntario. Dtection,
traitement et prophylaxie secondaire sont ncessaires.
CONCLUSION Le rhumatisme articulaire aigu nest
pas une maladie oublie et il existe toujours dans les
rgions recules du Canada.
475
Clinical Review
Levels of evidence
Level I: At least one properly conducted randomized
controlled trial, systematic review, or meta-analysis
Level II: Other comparison trials, non-randomized,
cohort, case-control, or epidemiologic studies, and
preferably more than one study
Level III: Expert opinion or consensus statements
476
Clinical Review
Conclusion
A low but substantial rate of ARF is present in the First
Nations population of northwest Ontario. A Cochrane
review recognizes its presence in emerging economies,
implicating socioeconomic factors. Physicians would
477
Clinical Review
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Correspondence
Dr S. Madden, Northern Ontario School of Medicine, Box 489, Sioux Lookout,
ON P8T 1A8; e-mail smadden@slmhc.on.ca
References
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prevention of acute rheumatic fever: a meta-analysis. BMC Cardiovasc Disord
2005;5(1):11-20.
2. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane
Database Syst Rev 2006;(4):CD000023.
3. Carapetis JR, Currie BJ, Mathews JD. Cumulative incidence of rheumatic
fever in an endemic region: a guide to the susceptibility of the population.
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4. Stollerman GH. Rheumatic fever in the 21st century. Clin Infect Dis
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chain that links the heart to the throat? Lancet Infect Dis 2004;4(4):240-5.
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Mme si rhumatisme articulaire aigu (RAA) est relativement rare dans les conomies dveloppes, il est
beaucoup plus frquent dans les rgions en voie de
dveloppement et chez les populations aborignes.
Des taux plus levs de RAA pourraient tre relis
la promiscuit et aux mauvaises conditions de vie.
Le diagnostic requiert 2 critres de Jones majeurs ou
1 majeur et 2 mineurs, en plus dune preuve dinfection antrieure au streptocoque. Les critres majeurs
incluent: cardite, polyarthrite, chore, rythme margin et nodules sous-cutans; les critres mineurs
comprennent: fivre, arthralgie, RAA ou cardite rhumatismale antrieurs, ractants de phase aigu et
prolongation de lespace PR llectrocardiogramme.
La plupart des cas de RAA peuvent tre prvenus
par un traitement antibiotique administr moins
de 9 jours aprs une pharyngite streptocoque du
groupe A. Une fois le RAA install, il ny a pas de
traitement efficace contre la raction immune. Les
salicylates procurent un soulagement de la fivre
et de larthrite, la prednisone peut tre utilise chez
les patients qui prsentent une chore, et la cardite
se traite par le repos au lit. La prophylaxie secondaire pour prvenir les rcidives est indique pour
tous les patients.